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177
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2 AUTHORS, INCLUDING:
Robert E Feinstein
University of Colorado
31 PUBLICATIONS 215 CITATIONS
SEE PROFILE
in the
Comprehensive
Psychiatry,
1990: pp 337-343
Medical Center
CT 06850.
337
338
With the general increase in crimes of violence over the past several decades, and
with complex legal issues raised by the Tarasoff case and others,8 there has been
increased concern with identifying violent individuals in the ER.9 Also of great
interest has been the question of how well psychiatrists can predict violent
behaviors, although most commentators on this issue have concluded that
prediction is poor. The problem is complex and far from being resolved.
The present study is concerned with three questions. First, what are the
differences on measures of violence and other indices, between ER patients who are
admitted to the inpatient service and those who are discharged? Second, to what
extent do measures of violence obtained in the ER correlate with indices of violence
for these same patients on the inpatient wards? Third, to what extent do measures of
suicidal behaviors obtained in the ER correlate with indices of suicidal behavior for
the same patient on the inpatient wards?
METHODS
Based on an extensive review of the literature, a Violence and Suicide Assessment form (VASA) was
constructed for the study. This form, shown in Table 1, covers 10 areas of interest. These are current
violent thoughts (during interview), recent violent behaviors (during the past several weeks), past history
of violent/antisocial/disruptive
behaviors (lifetime history), current suicidal thoughts, recent suicidal
behaviors, past history of suicidal behaviors, support systems, ability to cooperate, substance abuse, and
reactions during the interview. Within each area of interest there are a number of brief descriptions of
relevant behaviors varying in degree of severity or degree of psychopathology. For example, under the
area of current violent thoughts, the items and weights given to them are as follows: 4, expresses intense
wish to kill someone specific; 3, reveals command hallucinations to injure someone; 2, expresses
ambivalent wish to kill someOne specific; 1, expresses nonspecific feelings of rage or belligerence; and 0,
reveals no homicidal ideas. At the end of the rating scales, the clinician is asked to make a probability
estimate of the likelihood of suicidal ideation or behavior and a separate probability estimate of the
likelihood of violent ideation or behavior. The instructions given the clinicians are: Your probability
estimate (on a scale from 0 to 100) should refer to the next 3 weeks. In that period, do you expect that this
patient will show suicidal ideation or behavior and/or violent ideation or behavior?
This VASA form was used in the ER of a large municipal hospital by clinicians during a 4-month
period. During this time they evaluated 95 patients on the form as part of their usual screening,
evaluation, and treatment functions. The evaluations and decisions on a patient were made first. Then the
VASA form was completed. Patients in the study were selected from the psychiatric emergency service,
subject only to the need for voluntary cOnsent and being over the age of 1S years.
The design of the study was based on the idea that some of the ER patients would be hospitalized and
most would be discharged home or referred for further outpatient care. The final sample consisted of SO
discharged patients and 45 patients admitted to the inpatient wards.
Since the average length of stay of psychiatric patients at this hospital is approximately 3 weeks, all of
the admitted patients were discharged by the time the follow-up data collection period was instituted. For
each hospitalized patient, information was obtained on his (or her) number of seclusions, reasons for
seclusion, the number and nature of incident reports, the presence of suicide precautions, diagnoses,
discharge disposition, drugs used, and nursing notes relevant to suicidal or violent behavior. Based on this
information. several indices were constructed of violence-related or suicide-related ward behavior.
RESULTS
Table 2 presents the general demographic data for the patients, including sex
distribution, mean age, marital status, race, and diagnoses.
The two groups have approximately the same age and racial distribution, but the
inpatient group has relatively more single males. Inpatients also have a higher
frequency of multiple suicide attempts, more of a history of drug abuse, and more
signs of suicidality (gestures and ideation) at the time of admission. Twenty-three
Table 1. Violence
Scale
340
Admitted
Inpatients
(N = 45)
Outpatients
(N = 50)
33.4
34.2
Male
Female
62%
38%
38%
62%
Single
Married
Divorced
Separated
Widowed
66%
14%
11%
9%
0%
51%
26%
9%
5%
9%
35%
23%
40%
2%
38%
28%
34%
0%
5%
9%
86%
0%
10%
90%
38%
7%
14%
41%
27%
2%
6%
27%
Brought by police
23%
8%
Major depression
Dysthymia
Schizophrenia spectrum
Substance abuse
25%
3%
42%
31%
20%
15%
30%
35%
Variables
White
Black
Hispanic
Other
More than one prior suicide attempt
One prior suicide attempt
No prior suicide attempt
History
Suicide
Suicide
Suicide
as
percent of the inpatients were brought to the ER by the police, while only 8% of <he
discharged patients were brought by police. In terms of diagnoses, the inpatients
had more schizophrenic spectrum illnesses (schizophrenia, atypical and reactive
psychoses, schizoaffective disorders) and less dysthmia. The prevalence of major
depression and substance abuse disorder in the two groups was approximately the
same.
The psychometric properties of the rating scale were then examined. The first
three items were all concerned with violence, current, recent, and past. The internal
reliability of these three items as measured by coefficient alpha is .68, a reasonable
level of reliability. The coefficient alpha internal reliability of the next three items
concerned with suicide, current, recent, and past is .73, also satisfactory. When the
entire group of 10 items is considered as a scale, the alpha internal reliability is .79.
It thus appears that there is a high degree of interrelation among the violence items,
the suicide items, and the social support and motivational items. A total score on this
scale thus reflects the fact that suicidality, violence, lack of social support, refusal to
cooperate, substance abuse, and current interactional styles are all related. The total
score may thus be conceptualized as a psychosocial distress index.
VIOLENCE/SUICIDE
RISK ASSESSMENT
IN THE ER
341
Service Using
Discharged Patients
(N = 50)
Admitted Patients
(N = 45)
Items
Mean
SD
Mean
SD
.12
.38
1.36
.40
.44
.a8
1 .oo
.4a
.a2
.48
.92
2.83
.a1
1.03
1.61
1.18
.71
1.49
.a4
1.09
2.91
2.07
2.13
3.35
2.27
2.13
1.73
i .38
1.36
3.09
2.77
1.89
2.59
1.56
4.38
I .a2
3.34t
2.92t
2.52t
4.81$
5.33%
5.40$
4.433
2.50*
2.62*
.36
.92
1.84
2.50
3.75$
Total score
Suicide probability estimate
Violence probability estimate
6.24
20%
12%
6.71
17.3
14.8
19.38
52%
44%
9.26
30.5
30.6
7.84$
6.15$
6.154
lP < .05.
tP< .Ol.
SP< .OOl.
342
discriminate between those ER patients who were admitted to the inpatient service
and those who were not was examined for different cutoff scores. As typically found,
when specificity (i.e., the ability to identify true negatives) increased, sensitivity
(e.g., the ability to identify true positives) decreased. The optimum cutoff score for
maximum sensitivity and specificity was found to be 11. A score of this value
produced a sensitivity and specificity of approximately 82%.
DISCUSSION
The focus of this study has been on the initial assessment of violence or suicide
risk in a psychiatric ER and the extent to which such assessments are able to predict
certain aspects of the subsequent course of hospitalization. It was found that
patients who are immediately hospitalized after an initial ER evaluation are
somewhat different from those who are discharged home. They tend to be younger,
contain a higher proportion of males, are more likely to be single, have a more
frequent history of substance abuse, are more likely to have made multiple suicide
attempts in the past, and are more likely to present with suicidal ideation or
gestures.
All patients were assessed using an expanded lo-item version of the Bengelsdorf
et al (1984) triage rating system. The results showed that the ER patients admitted
to the inpatient wards scored significantly higher on every one of the items as well as
on total score. They also scored higher on the frequency of both prior suicide
attempts and violent episodes. These findings clearly indicate that the VASA scale
significantly discriminates between admitted and discharged ER patients. As
further support of this point, the sensitivity and specificity were both found to be
quite high (82%) using a cutoff score of 11. It thus appears that the VASA scale
may be a useful tool for clinicians in ERs to guide the clinical interview.
The second key question of the study was to examine whether initial ER data have
any predictive value in describing aspects of the course of short-term inpatient
hospitalization. The results indicate that the number of prior suicide attempts is
highly correlated with the likelihood of violent behavior in the hospital (r = .60). A
history of substance abuse is also highly correlated with the likelihood of violent
behavior in the hospital within 3 or 4 weeks after admission (r = .63). It was also
found that three items of the VASA scale (lifetime history of suicide attempts, lack
of social support systems, and inability to cooperate with the interviewer) correlate
significantly with suicide risk in the hospital (r = .41) as estimated from nursing
notes. It thus appears that some degree of prediction of acting out aggressive
behavior is possible over relatively short time periods, using simple clinically
obtained measures. We thus believe that the rating scales described here have value
for the clinician to help in the identification of patients who need to be hospitalized,
and may also serve as limited predictors of some aspects of hospital functioning.
ACKNOWLEDGMENT
The authors would like to thank Janie Lynn Feldman for assistance in data collection.
REFERENCES
1. Warner SL: Criteria for involuntary hospitalization of psychiatric patients in a public hospital.
Ment Hygiene45:122-128,196l
VIOLENCE/SUICIDE
RISK ASSESSMENT
IN THE ER
343